Painless Aortic Dissection: Presentation as GI Bleed. What do we Learn?

Aortic dissection is the most catastrophic clinical condition that involves the aorta. It has complex clinical manifestations as a result high delayed and missed diagnosis is not uncommon. Typically, it presents with acute chest, back and tearing abdominal pain. However, it can present atypically with minimal or no pain, making the diagnosis difficult. We present the case of a 78-year-old woman with past medical history of hypertension, deep venous thrombosis, diabetes and giant cell arteritis who presented with complaints of nausea, vomiting, anorexia and generalized weakness for 6 hours. She also complained of dull aching abdominal discomfort of few hours' duration. On arrival to ED, she had had two bloody bowel movements. On examination, BP 136/60 mmHg, HR 60/min, RR 20/min, SpO2 96% on room air. Pulses were equal in both arms and legs. Abdomen was non-tender, active bowel sounds. Rectal exam was positive for bright red blood. Laboratory test showed leukocytosis of 18.1 cells/mm3, lipase of 598 U/L, AST of 56 U/L, LDH of 344, negative troponin. Chest X ray was unremarkable. CT abdomen with contrast was done due to concerns for bowel ischemia. During imaging, patient suddenly became unresponsive. Resuscitative efforts and advanced life support were not initiated due to DNR/DNI status. Review of CT scan revealed dissection of aorta extending from aortic root to superior mesenteric artery and left common iliac artery (Figure 1-3). About 6.4% of acute aortic dissections are painless. Painless AAD is more prevalent among patients suffering from type A dissection than type B dissection and associated with increased mortality. The common presentations in painless dissection include syncope (33.9%), new-onset neurological deficit (23.7%), stroke, congestive heart failure (19.7%), coma or spinal cord ischemia (17.0%), acute renal failure (13.6%), myocardial infarction (7.1%), mesenteric ischemia (6.8%). Our case reinstates important learning point that when patients present with and/or develop signs and symptoms of ischemic bowel without obvious cause, aortic dissection should be considered, even without the presence of characteristic pain.